Underrecognition of Autism and Implications for Adult Psychiatric Practice: A Narrative Review

Autism in adulthood remains underrecognized across psychiatric settings despite epidemiological evidence supporting its persistence across the lifespan. Recognition is often hindered by heterogeneous presentation, misattribution of autistic traits to co-occurring psychiatric conditions, camouflaging processes, and limited integration of developmental history in adult assessments. This narrative review aims to synthesize current evidence on adult presentation and co-occurring conditions, examine barriers to identification, and propose a developmental, dimensional, and contextual framework for psychiatric assessment and formulation. A narrative review guided by the Scale for the Assessment of Narrative Review Articles was conducted. Peer-reviewed literature published between January 2010 and December 2025 was identified through structured searches of PubMed, Scopus, and Web of Science, with additional sources identified through reference list screening. Studies were selected based on conceptual relevance and applicability to adult psychiatric contexts. The literature indicates that autism in adulthood is characterized by marked heterogeneity, with presentations often shaped by internalized features, compensatory processes, and co-occurring psychiatric conditions. Across studies, these factors contribute to diagnostic overshadowing, delayed identification, and fragmented care trajectories. Developmental, neurobiological, and service-level evidence further highlights the influence of contextual and structural factors on recognition within adult psychiatric settings. Autism in adulthood is best conceptualized within a developmental, dimensional, and contextual framework. Improving identification in psychiatric practice requires systematic attention to developmental history, internal experience, compensatory processes, co-occurring conditions, and structural barriers. Integrating these elements may enhance clinical formulation, reduce diagnostic fragmentation, and improve care for autistic adults within psychiatric services.